不同浓度七氟醚麻醉对单肺通气时肺内分流量的影响

研究不同浓度七氟醚对低氧性肺血管收缩（ＨＰＶ）的影响，随机选择开胸手术３０例，观察三种浓度（０．５，１．０，１．５ＭＡＣ）七氟醚麻醉单肺通气后肺内分流（Ｑｓ／Ｑｔ）及氧分压（ＰａＯ２）的变化。结果显示：单肺通气后患者的Ｑｓ／Ｑｔ显著增加，ＰａＯ２明显下降；在１．５ＭＣ内，其变化程度与七氟醚浓度无明显关系。说明七氟醚对ＨＰＶ虽有抑制作用，但在一定深度范围内其抑制程度不随七氟醚浓度的增加而加重。     

不同浓度七氟醚麻醉对单肺通气时肺内分流量的影响

研究不同浓度七氟醚对低氧性肺血管收缩（ＨＰＶ）的影响，随机选择开胸手术３０例，观察三种浓度（０．５，１．０，１．５ＭＡＣ）七氟醚麻醉单肺通气后肺内分流（Ｑｓ／Ｑｔ）及氧分压（ＰａＯ＿２）的变化。结果显示：单肺通气后患者的显著增加，ＰａＯ＿２明显下降；在１．５ＭＡＣ内，其变化程度与七氟醚浓度无明显关系。说明七氟醚对ＨＰＶ虽有抑制作用，但在一定浓度范围内其抑制程度不随七氟醚浓度的增加而加重。     

静吸复合全麻与硬膜外阻滞麻醉联合应用于直肠癌根治术的研究

目的：比较静吸复合全麻联合硬膜外阻滞麻醉与单纯静吸复合全麻应用于直肠癌根治术时患者的血流动力学变化、吸入麻醉药用量、麻醉清醒时间和清醒质量的差别。方法：40例直肠癌根治术患者随机分为采用安氟醚为主的静吸复合全麻联合硬膜外阻滞麻醉组（I组）和单纯安氟醚为主的静吸复合全麻组（Ⅱ组），观察不同时相点血压和心率变化，吸入麻醉药用量、麻醉清醒时间和清醒质量。结果：同麻醉前相比，I组患者血压、心率基本平稳，Ⅱ组在不同时相点血压、心率升高幅度显著高于I组；I组安氟醚用量明显少于Ⅱ组（P＜0．01），麻醉清醒时间缩短，清醒质量明显提高（P＜0．01）。结论：静吸复合全麻联合硬膜外阻滞麻醉用于直肠癌根治术是一种更为安全、可控的麻醉方法。     

对不同麻醉方法胃次全切除术中血糖、乳酸、总蛋白、血球压积的观察

对比观察硬膜外麻醉与七氟醚为主的静吸复合全麻胃次全切除术中血糖、乳酸、总蛋白、血球压积等指标的变化。结果表明：血糖在硬膜外麻醉后９０ｍｉｎ较麻醉前非常显著升高（Ｐ＜０．０１），在静吸复合全麻４５、９０ｍｉｎ较麻醉前均显著升高，尤以９０ｍｉｎ为著（Ｐ＜０．０１）。乳酸在硬膜外麻醉后４５、９０ｍｉｎ较麻醉前显著升高（Ｐ＜０．０５），静吸复合全麻后４５、９０ｍｉｎ较麻醉前均有非常显著升高（Ｐ＜０．００１）。总蛋白、血球压积在硬膜外麻醉与静吸复合全麻前、后４５、９０ｍｉｎ均无明显变化     

Bain呼吸环路防治单肺通气犬肺内分流量增加的实验研究

对１５条单肺通气（ＯＬＶ）犬模型进行实验，观察手术侧肺加用或不用Ｂａｉｎ环路对犬肺分流量和氧合的影响。结果提示：与双肺通气（ＴＬＶ）相比，不用Ｂａｉｎ的ＯＬＶ犬，动，静脉氧分压，动，静脉血氧饱和度分别降低了４９％，１１％、８％、１４％；肺泡气与动脉血氧分压差，肺毛细血管－动脉血氧含量差，肺毛血管－静脉血氧含量差（ＣｃＯ２－ＣｖＯ２）和肺分流量（Ｑｓ／Ｑｔ），分别增加了３９％，３５０％、５０％和１９     

单肺通气时监测PETCO2的研究

目的：通过研究ＰａＥＴＣＯ２的变化和ＰＥＴＣＯ２与ＰａＣＯ２的相关性来评价单肺通气（ＯＬＶ）时监测ＰＥＴＣＯ２的价值。方法：选择３０例开胸手术的患者,分别于双肺通气（ＴＬＶ）２０ｍｉｎ、ＯＬＶ５ｍｉｎ,１５ｍｉｎ,３０ｍｉｎ,６０ｍｉｎ测ＰＥＴＣＯ２与ＰａＣＯ２的价值,计算ＰａＥＴＣＯ２,进行统计学处理。结果：ＯＬＶ时不同时段的ＰＥＴＣＯ２比ＴＬＶ时增大（Ｐ〈０．０５）,ＰＥＴＣＯ２与ＰａＣＯ２相     

安氟醚和七氟醚对腹部手术机体耗氧量的影响

对比安氟醚、七氟醚两种吸入麻醉药在腹部手术麻醉期间对机体耗氧量（ＶＯ２）的影响。方法选择择期腹部手术病３０例,ＡＳＡⅠ－Ⅱ级,随机分为安氟醚（Ｅ）组和七氟醚（Ｓ）组。记录手术开始前、麻醉吸醚后５ｍｉｎ及手术开始后３０、６０、９０、１２０、１５０ｍｉｎ时的吸入一呼出氧浓度差,分钟通气量,计算ＶＯ２。同时记录呼气末ＣＯ２浓度（Ｅ－ＴＣＯ２）,平均动脉压（ＭＡＰ）、心率（ＨＲ）,体温（Ｔ）,最低肺泡有效     

胸段硬膜外阻滞对气管拔管时心血管反应的影响

目的 观察胸段硬膜外阻滞对气管拔管期间心血管反应的影响，方法 选择３０例胸科择期手术病人，随机分成静吸全麻组（Ｑ组）和静吸全麻加硬膜外阻滞组（Ｙ组），分别于术毕符合气管拔管条件时吸痰，拔管，测定拔管前５ｍｉｎ到拔管后１０ｍｉｎ不同时间血流动力学参数。     

静吸全麻联合硬膜外阻滞用于胸科手术的临床观察

目的：观察静吸全麻联合硬膜外阻滞应用在胸科手术中无优势。方法：在胸科手术中采用静吸全麻联合胸段硬膜外阻滞麻醉，并与静吸全麻比较，监测插管后5、60min及拔管时和拔管后5min的收缩压（SBP）、舒张压（DBP）、心率（HR）。记录氨氟醚吸入浓度、芬太尼用量，以及手术结束至拔管时间，清醒程度及纳络酮使用例数。结果：两组SBP、DBP、芬太尼用量及术毕恢复质量有显著差异。结论：静吸全麻联合硬膜外阻滞能减少麻药用量，术中麻醉平稳，术毕恢复更及时。     

观察COPD患者肺分流测定的临床意义

目的：观察慢性肺心病急性发作期患者的肺内分流率（Ｑｓ／Ｑｔ）的变化。方法：用２１００型肺功能仪作为减压装置，让患者吸入纯氧２０ｍｉｎ后，使用血气分析仪进行吸氧前后血气分析，并计算Ｑｓ／Ｑｔ值。结果：３１例患者中，仅２例Ｑｓ／Ｑｔ正常，２９例均增高。并以Ｑｓ／Ｑｔ为应变量，ＰａＯ２、ＰａＣＯ２及ＳａＯ２为自变量，进行逐步回归，得出方程式。结论：低氧血症患者测定Ｑｓ／Ｑｔ，结合不同病因，有利于参估和选择合理的给氧方式，包括吸氧浓度。     

慢性肺动脉栓塞血栓内膜剥脱术围手术期管理

目的　探讨慢性肺动脉血栓内膜剥脱术围手术期管理的方法。方法　总结 7例慢性肺动脉栓塞剥脱术 (PTE)病例的临床资料。结果　 7例在体外循环下行肺动脉血栓内膜剥脱术 ,1例围术期死亡 ,6例存活。术后 2周测不吸氧状态下动脉血氧分压、血氧饱和度均有显著改善 (P<0 .0 5 ) ,术后 2周超声心动测肺动脉收缩压显著降低 (P <0 .0 5 ) ,生活质量明显改善。结论　术前术后积极降低肺动脉高压、纠正心功能不全 ,术后防治肺水肿及再栓塞的形成是肺动脉血栓内膜剥脱术围手术期管理的关键。     

闭塞性肺动脉高压的肺阻抗血流图

分析32例闭塞性肺动脉高压的肺阻抗血流图资料,并与右心导管检查相对照,结果表明闭塞性肺动脉高压的肺阻抗基本波形为多峰递增波,波峰延迟为其主要特点,延迟的程度与肺动脉压呈正相关。     

巨大性肺栓塞

巨大性肺栓塞是发生在肺动脉干和左右肺动脉内的栓子栓塞和血栓形成。5例巨大性肺栓塞中,4例肺动脉血栓形成继发于慢性肺心病和肺动脉高压症,另1例为肾癌术后的肺动脉栓塞。5例均发生猝死,临床无1例确诊为巨大性肺栓塞。文中对本病的发病情况、栓塞的来源和发病机制、病理改变和临床表现进行了讨论。     

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: preliminary exploration in China

Background Pulmonary endarterectomy is safe and effective surgical treatment for chronic thromboembolic pulmonary hypertension. This study aimed to evaluate the efficacy of pulmonary endarterectomy in treatment of thromboembolic pulmonary hypertension. Methods A retrospective study of 15 patients who underwent pulmonary endarterectomy in Beijing Chaoyang Hospital was performed. Obvious pulmonary hypertension and hypoxemia were observed in all patients. Bilateral pulmonary endarterectomy was performed under cardiopulmonary bypass with profound hypothermic circulatory arrest. Results Two patients （2/15） died of residual postoperative pulmonary hypertension and bleeding complication. The other 13 cases had significant decrease in systolic pulmonary artery pressure （（92.8＋_27.4） mmHg vs. （49.3＋18.6） mmHg） and pulmonary vascular resistance （（938.7±464.1） dynes.s.cm5 vs. （316.8±153.3） dynes＇s.cm5）, great improvement in cardiac index （（2.31：LK）.69） L.min-l.m2 vs. （3.85±1.21） L.min-l.m2）, arterial oxygen saturation （0.67±O.11 vs. 0.96±0.22） and mixed venous 02 saturation （0.52±0.12 vs. 0.74±0.16） postoperatively compared to preoperative data. Mid-term follow-up showed that the cardiac function of all cases returned to NYHA class I or II, with great improvement in 6-minute walking distance （（138±36） m） and quality of life. Conclusions Bilateral pulmonary endarterectomy using cardiopulmonary bypass with the aid of deep hypothermia and circulatory arrest can effectively reduce pulmonary hypertension and provide good mid-term hemodynamic and symptomatic results with low surgical mortality rate and few complications.     

Chronic thromboembolic pulmonary hypertension: a review

Chronic thromboembolic pulmonary hypertension (CTEPH) is a unique form of pulmonary hypertension resulting from obstruction of the pulmonary artery by fibrotic thromboembolic material, usually initiated by recurrent or incomplete resolution of pulmonary embolism. This distinct form of pulmonary hypertension is classified under Group 4 of the World Health Organization classification. Further investigations are usually initiated, with transthoracic echocardiography followed by right heart catheterisation and pulmonary angiography as the gold standard. Definitive treatment is usually in the form of surgical pulmonary endarterectomy. Inoperable CTEPH is medically treated with pharmacological agents such as phosphodiesterase Type 5 inhibitors, endothelin receptor antagonists, soluble guanylate cyclase stimulators and prostacyclin. Recent developments have made balloon pulmonary angioplasty a viable option as well.     

术前肺功能与肺切除术后并发症的关系

肺切除术后并发症风险性与术前肺功能和预期术后肺功能指标明显相关。在术前选择合适的病人手术，对于降低术后的死亡率和并发症率十分重要，其中最具代表性的指标为FEV1％、DLCO％、FEV1％PPO、DLCO％PPO等。     

大鼠高肺血流性肺动脉高压形成中肺血管结构的变化

目的探讨大鼠高肺血流性肺动脉高压形成中肺血管结构的动态变化规律.方法80只雄性SD大鼠,随机分为分流组和对照组,每组40只.分流组大鼠经腹主动脉-下腔静脉穿刺术建立高肺血流动物模型,对照组大鼠除不作穿刺术外,其余手术过程同分流组.两组分别在术后1、3 d及1、4、8周经右心插管法测量肺动脉收缩压(SPAP)、肺动脉平均压(MPAP);取心脏组织,称量右心室与左心室 室间隔重量之比[RV/(LV SP)];取肺组织制作光学显微镜及电子显微镜标本,在光镜下观察肺小动脉中肌型动脉(MA)、部分肌型动脉(PMA)及非肌型动脉(NMA)构成比例及MA的相对中膜厚度(RMT)和相对中膜面积(RMA)的变化,电镜下观察肺小动脉超微结构的变化.结果与对照组比较,SPAP和MPAP在分流组术后1、3 d及4周时差异无显著性,分流术后1、8周时,SPAP、MPAP均显著高于对照组(P＜0.01);分流术后8周,RV/(LV SP)显著升高(P＜0.05);与对照组比较,分流术后1、3 d及1周时MA、PMA、NMA占肺小血管总数的百分比在两组之间差异无显著性,分流术后4、8周时大鼠MA、PMA占肺小血管总数的百分比明显增高(均P＜0.01),而NMA百分比明显降低(均P＜0.01);RMT、RMA在分流术后1、3 d及1、4周与对照组比较差异无显著性;分流术后8周时明显增高(P＜0.05).肺小动脉超微结构在分流术后3 d时仅为内皮细胞肿胀、体积增大;分流术后1周时,除内皮细胞结构改变外平滑肌细胞增大、内弹力层厚薄不均;分流术后4周时平滑肌细胞与内弹力层呈垂直生长,由收缩表型向合成表型转化;分流术后8周时细胞间见胶原纤维堆积.结论肺血管结构重建呈现明显的时间依赖性,内皮细胞肿胀出现最早,平滑肌结构改变次之,最后出现细胞外基质异常堆积.     

室缺修补术并肺高压体外循环后肺通气和血流临床干预的效应对比

目的观察肺高压室缺修补术(左向右分流)患儿体外循环(cardiopulmonary bypass,CPB)后增加肺通气或扩张肺血管对肺内分流和肺顺应性的临床影响。方法3组(60例)患儿随机分为A组(对照组20例)常规呼吸管理、B组(20例)CPB后用前列腺素E1、C组(20例)CPB后增加肺通气量,观察CPB前、CPB后30分的动脉血二氧化碳分压(PaO2)和呼气末二氧化碳分压(PETCO2)的差值(Pa-ETCO2)、肺顺应性(Cmpl)、平均动脉压力(mean blood pressure,MBP)和肺内分流率(Qs/Qt)、呼吸指数(respiration index,RI)的变化。结果组内比较,CPB后30 min C组的Pa-ETCO2差值增加和Cmpl降低(P<0.05)、Qs/Qt和RI升高(P<0.05);B组的Pa-ETCO2、Qs/Qt和RI明显低于同时点C组(P<0.05或P<0.01),Cmpl高于同时点C组(P<0.05)。结论小儿心脏手术CPB后心肺功能正效应并不即时体现,肺部存在明显肺内分流及无效腔通气,通气/血流失调,肺顺应性减低,单纯增加通气量改善不大,扩张肺血管可明显改善肺顺应性、减少肺内分流。     

Pulmonary oligemia maneuver can alleviate pulmonary artery injury during pulmonary thromboendarterectomy procedure

Background Pulmonary thromboendarterectomy (PTE) has evolved as a treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to characterize if pulmonary oligemia maneuver (POM) can alleviate pulmonary artery injury during PTE procedure.

Methods A total of 112 cases of CTEPH admitted to Beijing Anzhen Hospital from March 2002 to August 2011 received PTE procedure. They were retrospectively classified as non-POM group (group A, n=55) or POM group (group B, n=57). Members from group B received POM during rewarming period, whereas members from group A did not.

Results There were three (5.45%) early deaths in group A, no death in group B (0) (Fisher’s exact test, P=0.118). Six patients in group A needed extracorporeal membrane oxygenation (ECMO) as life support after the PTE procedure, no patients in group B needed ECMO (Fisher’s exact test, P=0.013). The patients in group B had a shorter intubation and ICU stay, lower mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR), higher partial pressure of oxygen in artery (PaO₂) and arterial oxygen saturation (SaO₂) and less medical expenditure than patients in group A. With a mean follow-up time of (58.3 ± 30.6) months, two patients in group A and one patient in group B died. The difference of the actuarial survival after the procedure between the two groups did not reach statistical significance. Three months post the PTE procedure, the difference of residual occluded pulmonary segment between the two groups did not reach statistical significance (P=0.393).

Conclusion POM can alleviate pulmonary artery injury, shorten ICU stay and intubation time, and lower down the rate of ECMO after PTE procedure.

     

Pulmonary artery injury management during pulmonary thromboendarterectomy

Pulmonary thromboendarterectomy （PEA） is the recommended treatment for chronic thromboembolic pulmonary hypertension （CTEPH）.1 Pulmonary artery injury is a major risk factor during PEA performed at less experienced surgical centers and is associated with adverse short-term consequences.In-hospital mortality may be as high as 15% in some PEA case series,with pulmonary artery injury and persistent pulmonary hypertension as the principal etiologies.2 Many techniques have been used to prevent pulmonary artery injury during PEA,but once the injury occurs,the prognosis is poor and may even result in death.Out of 202 PEA procedures performed at our surgical center,we successfully managed two cases of severe pulmonary artery injury and report our experience in the present case series.Keywords：chronic thromboembolic pulmonary hypertension; pulmonary thromboendarterectomy; pulmonary artery injury